Giant calcified chronic subdural haematoma: a long term complication of shunted hydrocephalus
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《神经病学神经外科学杂志》
Department of Neurosurgery, Xijing Hospital, China
Correspondence to:
Dr He Xiaosheng
Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi 710032, China; hexiaos@fmmu.edu.cn
Keywords: Calcification; haematoma; hydrocephalus; shunt; subdural
A 15 year old boy, who had undergone ventriculo-peritoneal (VP) shunting for hydrocephalus at age 5, presented with a several-month history of progressive right hemiparesis, headache, and urinary incontinence for 3 weeks. Clinical examination revealed grade 3 power (MRC classification) in the right limbs. Cranial computed tomography (CT) showed a high density mass with surface calcification (fig 1A–D).
Figure 1 (A–D) Preoperative cranial CT. Cranial CT scans revealed a higher density mass with significant calcification around its surface, occupying larger intracranial space.
Preoperatively it was considered he had a chronic, calcified subdural haematoma from VP shunt overdrainage. The mass was removed via craniotomy and confirmed organised subdural blood clot, which was thickly calcified on its surface. Seven days post operation, CT revealed that the haematoma had been totally resected, the brain had expanded, and the lateral ventricles were large (fig 2A–D).
Figure 2 (A–D) Postoperative cranial CT. At 7th day post operation, cranial CT scans manifested that calcified and organised subdural haematoma was totally removed, and CSF was accumulated in lateral ventricles and expanded outwards cerebral parenchyma that occupied the residual space at which the subdural haematoma had been located.
One month later his preoperative motor symptoms had resolved. Over the next year his mental status improved and he became capable of all activities of daily living despite persistent hydrocephalus on serial CT scans. He was considered to have compensated chronic hydrocephalus.
Calcification of chronic subdural haematomas, which are caused by over drainage of cerebrospinal fluid (CSF) by shunting,1 is not common. Several reported cases have been asymptomatic,2 implying that CSF is shunted enough to maintain normal intracranial pressure. Bilateral calcified subdural haematomas—"armoured brain"—can, however, result in severe symptoms.3–5 Excision of the haematoma can—as in this patient—lead to good outcome.
References
Tuli S, Drake J, Lawless J, et al. Risk factors for repeated cerebrospinal shunt failures in pediatric patients with hydrocephalus. J Neurosurg 2000;92 (1) :31–8.
Barmeir EP, Stern D, Harel S, et al. Calcified subdural hematomas associated with arrested hydrocephalus--late sequelae of shunt operation in infancy. Eur J Radiol 1985;5 (3) :186–9.
Spadaro A, Rotondo M, Di Celmo D, et al. Bilateral calcified chronic subdural hematoma. Further pathogenetic and clinical consideration on the so-called "armored brain". J Neurosurg Sci 1987;31 (2) :49–52.
Sharma RR, Mahapatra A, Pawar SJ, et al. Symptomatic calcified subdural hematomas. Pediatr Neurosurg 1999;31:150–4.
Ersahi Y, Mutluer S. Calcified subdural hematoma. Pediatr Neurosurg 2000;32:165–6.(X S He and X Zhang)
Correspondence to:
Dr He Xiaosheng
Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi 710032, China; hexiaos@fmmu.edu.cn
Keywords: Calcification; haematoma; hydrocephalus; shunt; subdural
A 15 year old boy, who had undergone ventriculo-peritoneal (VP) shunting for hydrocephalus at age 5, presented with a several-month history of progressive right hemiparesis, headache, and urinary incontinence for 3 weeks. Clinical examination revealed grade 3 power (MRC classification) in the right limbs. Cranial computed tomography (CT) showed a high density mass with surface calcification (fig 1A–D).
Figure 1 (A–D) Preoperative cranial CT. Cranial CT scans revealed a higher density mass with significant calcification around its surface, occupying larger intracranial space.
Preoperatively it was considered he had a chronic, calcified subdural haematoma from VP shunt overdrainage. The mass was removed via craniotomy and confirmed organised subdural blood clot, which was thickly calcified on its surface. Seven days post operation, CT revealed that the haematoma had been totally resected, the brain had expanded, and the lateral ventricles were large (fig 2A–D).
Figure 2 (A–D) Postoperative cranial CT. At 7th day post operation, cranial CT scans manifested that calcified and organised subdural haematoma was totally removed, and CSF was accumulated in lateral ventricles and expanded outwards cerebral parenchyma that occupied the residual space at which the subdural haematoma had been located.
One month later his preoperative motor symptoms had resolved. Over the next year his mental status improved and he became capable of all activities of daily living despite persistent hydrocephalus on serial CT scans. He was considered to have compensated chronic hydrocephalus.
Calcification of chronic subdural haematomas, which are caused by over drainage of cerebrospinal fluid (CSF) by shunting,1 is not common. Several reported cases have been asymptomatic,2 implying that CSF is shunted enough to maintain normal intracranial pressure. Bilateral calcified subdural haematomas—"armoured brain"—can, however, result in severe symptoms.3–5 Excision of the haematoma can—as in this patient—lead to good outcome.
References
Tuli S, Drake J, Lawless J, et al. Risk factors for repeated cerebrospinal shunt failures in pediatric patients with hydrocephalus. J Neurosurg 2000;92 (1) :31–8.
Barmeir EP, Stern D, Harel S, et al. Calcified subdural hematomas associated with arrested hydrocephalus--late sequelae of shunt operation in infancy. Eur J Radiol 1985;5 (3) :186–9.
Spadaro A, Rotondo M, Di Celmo D, et al. Bilateral calcified chronic subdural hematoma. Further pathogenetic and clinical consideration on the so-called "armored brain". J Neurosurg Sci 1987;31 (2) :49–52.
Sharma RR, Mahapatra A, Pawar SJ, et al. Symptomatic calcified subdural hematomas. Pediatr Neurosurg 1999;31:150–4.
Ersahi Y, Mutluer S. Calcified subdural hematoma. Pediatr Neurosurg 2000;32:165–6.(X S He and X Zhang)